Preventing Avoidable Readmissions Driver Diagram

Primary Drivers Secondary Drivers Change Ideas
Self-management skills • Enhance patients’/caregivers’ knowledge
about the medications prescribed.
• Enhance patients’/caregivers’ knowledge
about their symptoms, red flags, and selfcare
strategies.
• Identify and address patients’ health literacy and
activation levels.
• Use Teach-back to validate patient understanding.
•
• Obtain an accurate home medication history from the patient and/or
primary caregiver at admission.
Educate patients/caregivers before discharge regarding all
medications prescribed, the purpose of these medications,
the means of obtaining them, and the instructions for taking
them.
• Provide clearly written medication instructions using health
literacy concepts and culturally appropriate training
materials.
• Develop patient-centered educational tools that employ health literacy
concepts to teach patients about their diagnosis and symptoms.
• Train clinical staff on Teach-back using role play, and observe their
technique in the field. Do they…
o Use “I” statements when speaking with patients and
caregivers? “To make sure I did a good job explaining
your medications, can you tell me …?”
o Validate patient and caregiver understanding of
discharge instructions?
Coordination of information along the care
continuum
• Create a patient-centered record.
• Timely communication with members of the care
team who are not hospital-based.
•
• Accurate medication reconciliation at
admission, at any change in the level of care,
and at discharge.
• Evaluate best practices and resources and established
tools such as the Project RED After Hospital Care Plan (AHCP) and
Coleman Personal Health Record.
• Determine which models will work in your organization.
• Engage IT support for completing plans of care.
• Determine where key information is to be stored and how it
will be compiled to complete plans of care.
• Obtain accurate information about patients’ primary care physicians
at the time of admission.
• Send completed discharge summaries to patients’ primary care
physicians within 48 hours of discharge.
• Use of a concise, standardized discharge transfer form.
• Assign clear accountability for medication reconciliation and
perform reconciliation at each transition of care; consider a home
visit to educate patients/caregivers about their medications and to
reconcile the medications in the patients’ homes.